May 2015

A long, frustrating search for plantar fasciitis relief

9_FA_patient_perspBy P.K. Daniel

My husband Phillip and I used to live in Manhattan Beach, CA, a charming and affluent coastal town just south of Los Angeles. We resided two blocks from the wide, sandy beach. We took advantage of The Strand—a pair of concrete pathways that run for about two miles in front of many multimillion-dollar homes. One path is reserved for bikes and other wheeled toys, like roller blades and skateboards. The other path is for pedestrians.

In a place like that, with palm trees dotting the landscape and the Pacific Ocean as the backdrop, it’s pretty hard to come up with excuses not to exercise. I would bike, rollerblade, run, and walk several times a week, often in an effort to drop weight. As a former gymnast, I had experienced my share of injuries, but exercising had never resulted in any major physical ailments.

Less than a year after we were married, I received a job offer in San Diego, and we moved to La Jolla, another beach town. There, we would run together on the beach at low tide. Mostly, I would run barefoot. Other times, we would run through the winding, hilly neighborhoods of Bird Rock, admiring the varied architecture of more multimillion-dollar homes.

After a year of ineffective conservative interventions and two denials of coverage for custom foot orthoses, seeking a second opinion finally led to pain relief.

First symptoms

But not long after our runs would finish, I noticed the bottom of my right heel would start to ache. Sometimes, the pain would extend to my arch. When the discomfort became persistent, I knew I needed to get it checked out. My primary care doctor referred me to a podiatrist in the Division of Orthopedic Foot and Ankle Surgery at Scripps Clinic Medical Group in Rancho Bernardo, CA.

The podiatrist diagnosed me with plantar fasciitis. He recommended not running barefoot on the beach. He told me to ice my heel after working out. He gave me stretching exercises and said to roll my foot over a tennis ball. He treated me with corticosteroid injections and recommended oral anti-inflammatory medications and prefabricated functional orthoses (open-cell polyurethane foam [PPT] orthoses). The measures seemed to be successful in relieving my heel pain in just a few weeks.

As my life changed over the next few years, so did my exercise habits. Phillip and I bought a house and moved inland. We had two children over three years. My easy access to oceanfront exercising, as well as its appeal, dried up. I still would exercise—usually rollerblading while pushing a jogging stroller around a lake—but certainly not with the consistency I once had. The heel issue was, however, still at bay.

Recurrence, with a vengeance

Fast-forward seven years. Fueled by another weight-loss resolution, I started exercising again. I was walking hills, climbing steps, and running on a treadmill. But about four months after I resumed working out, the ache in my right heel returned. The hills seemed to make my condition worse. Then one morning, upon waking, I pushed the sheets back and swung my legs over the side of the bed. My feet hovered above the hardwood floor. I had no idea the next moments, as my right heel made contact with the floor and I attempted to take a few steps, would result in the most excruciating pain I had ever felt. The pain was sharp and stabbing. I figured the thick ligament that spans from the heel bone to the metatarsal heads had pulled or torn.

As the day wore on, the pain would become more bearable. But at rest, the tissue would contract, and the whole process would be repeated the next morning.

I could no longer ignore the excruciating condition I had been dealing with for two months. Seven and a half years after I was first seen for plantar fasciitis, I presented to the same podiatrist as a 42-year-old with recurrent plantar fasciitis. At the time, I was still using the PPT devices I had purchased years earlier.

I requested my medical records, including operative and procedure reports and progress notes, for this column. In those records, the podiatrist wrote: “There was focal tenderness to the plantar fascia insertion to the calcanei. There was no pain with calcaneal compression. She functions moderately hyperpronated in stance and gait. No significant edema, erythema, or temperature changes noted on either foot. Neurovascular status is grossly intact.”

Climbing steps was one of the activities that seemed to spur the recurrence of the author’s plantar fasciitis. (Photo by Karen Beaumont.)

Climbing steps was one of the activities that seemed to spur the recurrence of the author’s plantar fasciitis. (Photo by Karen Beaumont.)

His assessment was that I had plantar fasciitis. He recommended the use of motion-control shoes and arch supports. He also suggested calf-stretching exercises, ice massage after activity, and, again, to avoid barefoot running. I was told to return for a follow-up visit in six weeks, at which time a corticosteroid injection would be considered.

I had not run barefoot for years, so that wasn’t an issue. I discontinued walking hills. I gave up wearing Keds, a shoe that in retrospect wasn’t providing me enough support. I invested in an expensive pair of supportive Mephisto sandals. I was religious about icing after walking. I rolled my foot over a tennis ball. I did the stretching exercises prescribed. I did everything I was told to do, but I was still in pain.

Sometimes my job as a copy editor found me standing on my feet on a hard surface for a prolonged period of time. Other times, my job required me to sit at a computer, sometimes for hours at a time. When I would get to a stopping point—usually after deadline—I would dread what would come next. I knew the burning pain of the first few steps would be barely tolerable.

Frustration

I dutifully returned to the podiatrist six weeks later. He again noted “focal tenderness at the plantar fascia insertion on the right and no pain with calcaneal compression.” He again said there was “no significant edema, erythema, or temperature change.”

I expressed my frustration at the lack of improvement. I also was having difficulty with the over-the-counter arch supports. The supports limited the type of shoes I could wear. They would also slip inside my shoes. The doctor put in for an authorization for custom foot orthoses. He also ordered a night splint. He gave me a corticosteroid injection. I was scheduled to return for a follow-up appointment in three weeks.

The night splint I received is a bilateral spring-loaded tensioning device to help increase joint range of motion (ROM) due to shortened connective tissue. I had to sleep with this heavy, metal contraption with protruding parts. It was uncomfortable and potentially dangerous for my husband, as I had difficulty turning over in bed with this thing on my leg.

After three weeks, I returned and reported my heel pain was approximately 20% improved. In his report, the podiatrist described me as “having tolerated the [splint] relatively well.” However, that is not my recollection. While he had recommended custom orthotic devices, my insurance carrier denied coverage. I did not have substantial improvement with the corticosteroid injection. I also was complaining of rather severe lateral pain in my right leg.

Now, when the author returns to the beach, it’s for shod walking rather than barefoot running. (Photo by Karen Beaumont.)

Now, when the author returns to the beach, it’s for shod walking rather than barefoot running. (Photo by Karen Beaumont.)

The podiatrist noted “tenderness in the peroneal muscle belly on the right. Plantar fascia insertion is focally quite tender with palpation. There is no pain with calcaneal compression. Dorsiflexion at the right ankle is approximately 10° in the extended position. She has very poor motion control.”

His assessment: “Recalcitrant plantar fasciitis. Peroneal muscle strain secondary to first ray instability.”

The plan: “The importance of custom orthotics to stabilize the medial column of the foot was again emphasized. She will appeal the denial of custom orthotic coverage. I have also encouraged continued use of the [night splint] and calf stretching in addition to ice massage and the use of Aleve as needed. She will return for follow-up of orthotic casting once her appeal has been processed.”

Second opinion

My appeal for custom orthoses was denied. After dealing with the plantar fasciitis issue for several months and seeing only a modicum of improvement from the various treatments, I decided to seek a second opinion. I made an appointment with Gregory Clark, DPM, who heads the Podiatry Division in the Department of Orthopedic Surgery at the Scripps inic in La Jolla, CA.

He and I discussed the significant pain on the plantar aspect of the right foot, which he confirmed was insertional plantar fasciitis. I told him how I had previously responded to the use of orthoses and injections of local anesthetic and steroids. In fact, I had done relatively well since my first bout until I experienced this recurrence that began approximately one year earlier.

According to his assessment, I had exquisite sensitivity on the plantar aspect of my right heel, which was present during ambulation, as well as when returning to activity following rest. I could not relate a history of trauma to the onset of this condition.

I exhibited significant hypersensitivity with palpation to the plantar medial aspect of the right heel at the area of the medial calcaneal tuberosity. There was no evidence of edema, erythema, ecchymosis, or other sign of injury at this point. The vascular status of the foot was normal, Clark said, and neurologic status was intact. He noted a relatively mild cavus foot type and no evidence of bony abnormality on radiographs.

We spoke at length about the nature of my condition. We talked about the interventions that had been utilized to that point, which he described as fully reasonable and appropriate. Although I no longer engaged in barefoot running, the subject came up. Like the first podiatrist, Clark was not a fan.

“Barefoot running may work for a well-conditioned athlete who is acutely in tune with his body and can make the needed adjustments and adapt his gait and running style,” Clark told the Union-Tribune San Diego in a May 11, 2010, article. “However, for the casual runner who’s 45 years old and 30 pounds overweight, running barefoot, especially if the proper (precautions) aren’t taken, could end up being a problem. Running barefoot or with some kind of minimalist shoe should be done with significant caution.”

A different approach

We also discussed the failure of the alternatives used and the options of cast immobilization versus surgical percutaneous plantar fascia release. We decided to make use of a short-length walking cast. However, I would have to return at a later date when I had a driver to accompany me. I came back to the office a week or so later, and an orthopedic technologist applied neon pink Fiberglass casting tape.

It didn’t take long to adjust to walking in the cast. I probably wasn’t supposed to drive with it on, but three weeks is a long time to be dependent on someone else for transportation. When the time was up, I was eager to return to the doctor’s office for its removal. I recall expressing optimism that the chronic and persistent pain in my foot would be completely resolved. However, the real test would come when I ambulated on the foot without the cast in place.

Clark observed upon removal of the cast that there was no evidence of edema, erythema, ecchymosis, or other injury to the heel. There also was no significant tenderness with palpation on the plantar medial aspect of the heel at this point. I was also able to walk on my heel without any discomfort.

After the removal of the cast, the plan was for me to very gradually return to normal shoes and activity. I was advised to return to Clark’s care as needed. Nearly eight years later, I have had no need to return. While once in a long while, I will get a twinge in my right arch or heel that will momentarily alarm me, I have not had a recurrence of plantar fasciitis. Granted, I now avoid running and hills, but I do walk fairly regularly. While running helped me to lose weight, I never enjoyed it, even with the ocean views. In fact, I mostly hated it. And because of those recurrent episodes of plantar fasciitis, why would I ever chance it?

In retrospect

Looking back, when it became clear that custom foot orthoses weren’t going to be covered by my insurance carrier, and that I wasn’t going to pay $400 to $600 for them, I wish the first podiatrist had come up with an alternative treatment plan. I also wish he had offered me the option of casting. I wasn’t even aware that it was a possibility. But, because I wasn’t getting resolution with the various treatment options he offered, I felt I had to consider a second opinion. I am thrilled that I did.

Clark listened to me. He saw that we had already tried the standard treatments. He offered me a potential fix that I was eager to try. Being in a short walking cast for three weeks was a small price to pay for years of relief from a problem that had hounded me and significantly impacted my quality of life.

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